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New Pembina Hwy Location NOW OPEN!

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Located both in the Pembina Crossing Mall & on Regent Avenue, Winnipeg, MB

Hours & Location
- Pembina
- Regent Avenue
Our Optometric Team
Eye Care Services
- Dry Eye Treatment
Eyeglasses & Frames
Contact Lenses
Insurance Plans
Order Contacts

Hours & Location
- Pembina
- Regent Avenue
Our Optometric Team
Eye Care Services
- Dry Eye Treatment
Eyeglasses & Frames
Contact Lenses
Insurance Plans
Order Contacts

Home » SPEEDTM QUESTIONNAIRE

SPEEDTM QUESTIONNAIRE

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

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Sex:

M

F

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DOB:

MM slash DD slash YYYY

Email(Required)

Phone(Required)

For the Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire, please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness

At this visit

Within past 72 hours

Within past 3 months

Soreness or Irritation

At this visit

Within past 72 hours

Within past 3 months

Burning or Watering

At this visit

Within past 72 hours

Within past 3 months

Eye Fatigue

At this visit

Within past 72 hours

Within past 3 months

2. Report the FREQUENCY of your symptoms using the rating list below:

Dryness, Grittiness or Scratchiness(Required)

Never

Sometimes

Often

Constant

Soreness or Irritation(Required)

Never

Sometimes

Often

Constant

Burning or Watering(Required)

Never

Sometimes

Often

Constant

Eye Fatigue(Required)

Never

Sometimes

Often

Constant

3. Report the SEVERITY of your symptoms using the rating list below:

Dryness, Grittiness or Scratchiness(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

Soreness or Irritation(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

Burning or Watering(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

Eye Fatigue(Required)

No Problems

Tolerable - not perfect, but not uncomfortable

Uncomfortable - irritating, but does not interfere with my day

Bothersome - irritating and interferes with my day

Intolerable - unable to perform my daily tasks

4. Do you use eye drops for lubrication?(Required)

Yes

No

How often?(Required)

Total SPEED score

Δ

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Crest Eyecare

1866 Pembina Hwy, Unit 2
Winnipeg, MB R3T6J1

Phone: 204-421-8080
Phone: ext 1
Fax: 204-306-8596
Email: pembina@cresteyecare.com
(Do not send personal health information by email.)

Monday: 9:30 AM - 5:30 PM
Tuesday: 9:30 AM - 5:30 PM
Wednesday: 9:30 AM - 5:30 PM
Thursday: 10:30 AM - 6:30 PM
Friday: 9:30 AM - 5:00 PM
Saturday: 10:00 AM - 4:00 PM
Sunday: Closed

Crest Eyecare

1500 Regent Avenue West, Unit 9
Winnipeg, MB R2C3A8

Phone: 204-421-8080
Phone: ext 2
Fax: 204-221-8282
Email: regent@cresteyecare.com
(Do not send personal health information by email.)

Monday: 9:30 AM - 5:30 PM
Tuesday: 11:30 AM - 7:00 PM
Wednesday: 11:30 AM - 7:00 PM
Thursday: 9:30 AM - 5:30 PM
Friday: 9:30 AM - 5:00 PM
Saturday: 10:00 AM - 4:00 PM
Sunday: Closed

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Home
Contact Us
What’s New
Disclaimer
Privacy Policy

Schedule Appointment

Speak Field

Pembina Location NOW OPEN!

Crest Eyecare
1866 Pembina Hwy, Unit 2
Winnipeg, MB R3T6J1
Phone: 204-421-8080
https://www.cresteyecare.com

Crest Eyecare
1500 Regent Avenue West, Unit 9
Winnipeg, MB R2C3A8
Phone: 204-421-8080
https://www.cresteyecare.com

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